Lactation Consult Request Form

I am*
- a parent, and live in South Kaipara (Helensville, Kaukapakapa, South Head, Kumeu, Huapai, Woodhill, Parakai, Waimauku, Muriwai, Waitoki, and Riverhead)
- a parent, and I have been cared for by a HBC Midwife
- a Health Care Professional. Please enter your contact details
- other
Additional information

Please provide Health Care Professional contact details or 'other' information
First name
Last name
Address

Please include Suburb or Area
Phone number
Email
Mother's Date of birth

Day
Month
Year
Mother's NHI number
Baby's name
Baby's date of birth

Day
Month
Year
Baby's NHI number
Reason for consult

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